Understanding complexity – the palliative care situation as a complex adaptive system

Abstract

BackgroundThe concept of complexity is used in palliative care (PC) to describe the nature of patients’ situations and the extent of resulting needs and care demands. However, the term or concept is not clearly defined and operationalised with respect to its particular application in PC. As a complex problem, a care situation in PC is characterized by reciprocal, nonlinear relations and uncertainties. Dealing with complex problems necessitates problem-solving methods tailored to specific situations. The theory of complex adaptive systems (CAS) provides a framework for locating problems and solutions.This study aims to describe criteria contributing to complexity of PC situations from the professionals’ view and to develop a conceptual framework to improve understanding of the concept of “complexity” and related elements of a PC situation by locating the complex problem “PC situation” in a CAS.MethodsQualitative interview study with 42 semi-structured expert (clinical/economical/political) interviews. Data was analysed using the framework method. The thematic framework was developed inductively. Categories were reviewed, subsumed and connected considering CAS theory.ResultsThe CAS of a PC situation consists of three subsystems: patient, social system, and team. Agents in the "system patient" are allocated to further subsystems on patient level: physical, psycho-spiritual, and socio-cultural. The "social system" and the "system team" are composed of social agents, who affect the CAS as carriers of characteristics, roles, and relationships. Environmental factors interact with the care situation from outside the system. Agents within subsystems and subsystems themselves interact on all hierarchical system levels and shape the system behaviour of a PC situation.ConclusionsThis paper provides a conceptual framework and comprehensive understanding of complexity in PC. The systemic view can help to understand and shape situations and dynamics of individual care situations; on higher hierarchical level, it can support an understanding and framework for the development of care structures and concepts. The framework provides a foundation for the development of a model to differentiate PC situations by complexity of patients and care needs. To enable an operationalisation and classification of complexity, relevant outcome measures mirroring the identified system elements should be identified and implemented in clinical practice.Electronic supplementary materialThe online version of this article (10.1186/s12913-019-3961-0) contains supplementary material, which is available to authorized users.

Review of complex adaptive systems in nursing practice

“…Nevertheless, the term or definition for its specific application in PC is not clearly defined and operationalized. A care situation in PC is characterized by mutual, nonlinear relationships and uncertainties as a complex problem [14]. Dealing with complex problems requires methods to solve problems that are adapted for specific situations.…”

“…The "social system" and the "system team" are made up of social agents that influence the CAS as carriers of characteristics, roles and relationships. Environmental factors from outside the system interact with the situation of care subsystem agents and subsystems interact on all hierarchical system levels and shape the system behavior of a PC situation [14].…”

Which Reimbursement System Fits Inpatient Palliative Care? A Qualitative Interview Study on Clinicians' and Financing Experts' Experiences and Views

“…For more methodological details, see Supplementary Table S1 (COREQ criteria), Supplementary Table S2 (interview guide) and a related publication of this study. 26…”

QALY-Time: Experts’ View On The Use Of The Quality-Adjusted Life Year In Cost-Effectiveness Analysis In Palliative Care

“…(8)(9)(10) Among others because of the complexity of needs of palliative patients, which can be diverse and vary from symptom relief to information needs and autonomy to make decisions, to psychosocial support for coping with their disease, or spiritual and existential questions. (11) The QALY debate in palliative care was recently mapped in an integrative review. (12) In three themes, this review described which problems are encountered when using the QALY in the palliative care context: restrictions in life years gained; conceptualization of QoL and its measurement including suggestions to adapt this, and; issues around valuation and additivity of time, referring to changing valuation of time.…”